Neuropsych conference
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Neuropsych Conference. March 16, 2012 Block 10A. General Data. R. DR 4 4/M Married Right-handed Unemployed From Muntinlupa CC : behavioral changes. Profile. History of trauma, s/p craniotomy (2008) Diagnosed with seizure disorder (2009) Phenobarbital ½ gr. BID, poor compliance

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Neuropsych Conference

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Neuropsych conference

Neuropsych Conference

March 16, 2012

Block 10A


General data

General Data

R. DR

44/M

Married

Right-handed

Unemployed

From Muntinlupa

CC: behavioral changes


Profile

Profile

  • History of trauma, s/p craniotomy (2008)

  • Diagnosed with seizure disorder (2009)

    • Phenobarbital ½ gr. BID, poor compliance

    • Last seizure: Jan 23, 2012

  • PTB, adequately treated

  • Alcoholic beverage drinker: 20 years


  • History of present illness

    History of Present Illness

    • 4 mos. PTA

      • (+) behavioral changes, insomnia, anorexia

      • (+) auditory hallucinations

      • episodes of intoxication  violent behavior wife and children left


    History of present illness1

    History of Present Illness

    • 4 mos. PTA

      • Seizure episode

        • Stiffening of extremities

        • Upward rolling of eyes

        • Drooling

        • Loss of consciousness

        • Post-ictal confusion

      • Brought to PGH  managed as a case of seizure disorder


    History of present illness2

    History of Present Illness

    Interim:

    • Poor compliance (Pb BID)  recurrence of seizure episodes (last Jan 23, 2012)

    • Advised to consult at Psych OPD  lost to follow up

    • Persistence of violent behavior, auditory hallucinations and paranoia  consult  admission


    Review of systems

    Review of Systems

    (-) Weight changes

    (-) Fever

    (-) Headache

    (+) BOV

    (-) Nausea, vomiting

    (-) Cough/colds

    (-) Chest pain

    (-) DOB

    (-) Abdominal pain

    (-) Changes in bowel movement

    (-) Dysuria/hematuria

    (-) Tremors

    (-) Palpitation


    Past medical history

    Past Medical History

    As stated

    No DM, HPN, asthma, allergies, kidney/liver disease

    No other hospitalization/surgery


    Family medical history

    Family Medical History

    (+) Hypertension - mother

    (+) Heart disease – mother

    (-) Diabetes / stroke / epilepsy / asthma / allergy

    (-) Psych illness

    (+) Substance abuse – sibling

    (+) Kidney disease -sibling


    Personal social history

    Personal/Social History

    • Currently unemployed

    • Used to live with wife and 3 children (ages 9, 8 and 7)

    • Alcoholic beverage drinker – 20 yrs

    • (+) smoking – since elementary, consuming 1-2 packs per day


    Anamnesis

    Anamnesis

    Informant: patient

    Born full term via SVD to a then 32y/o G7P6 (6006) mother, no fetomaternal complications

    Childhood: shy but had close friends; average in school


    Neuropsych conference

    • Adulthood:

      • Finished 2nd year of Criminology due to illicit drug use and alcohol drinking

      • (+) MAP use, other drugs  sometimes hurts himself

      • Held several jobs (bartender, waiter, factory worker)

      • Felt that his coworkers were gossiping about him  (+) violence against a coworker

      • Once a full time preacher of El Shaddai

      • Had 2 intimate relationships: married in 2011, has 3 children


    Neuropsych conference

    • 2009

      • Vehicular crash (jeepneyvs pedestrian); intoxicated

      • s/p craniotomy

      • Post-op: worse alcohol drinking, episodes of forgetfulness


    Physical exam

    Physical Exam

    Awake, alert,follows commands, NICRD

    BP 120/80

    PR 88

    RR 20

    T 36.8


    Systemic examination

    Systemic Examination

    • Head and Neck

      • Anictericsclerae, pink conjunctivae, (-) masses/discharge, (-) CLAD, (-) anterior neck mass, (-) dentition

      • (+) skull depression, right temporal area

    • Chest

      • Equal chest expansion, clear breath sounds

    • Heart

      • Adynamicprecordium, distinct heart sounds S1 and S2, normal rate regular rhythm, (-) murmurs


    Neuropsych conference

    • Abdomen

      • Flabby, normoactive bowel sounds, soft, nontender

      • (+) several hypertrophic linear scars, midline

    • Skin / Extremities

      • Full equal pulses, pink nailbeds, (-) cyanosis/clubbing/edema

      • (+) multiple hyperpigmented scars on ventral side of forearm


    Assessment

    Assessment

    • Axis I:

      • Psychosis sec. to general medical condition (seizure disorder)

      • Major depressive disorder

      • Alcohol dependence, in controlled environment

    • Axis II: deferred

    • Axis III: Seizure disorder, s/p craniotomy, evacuation of hematoma (2009)

    • Axis IV: Poor primary support; economic problems

    • Axis V: GAF 31-40


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